Archive for September, 2010

No Snark Here

Up again at 0430, ear throbbing, after a restless night of fever and confused dreams. A comfortable cup of strong coffee, some pain meds, a dose of antibiotics, and one can begin to size up the world.

Bleh. Hardly doing anything that required more than thirty seconds of focussed attention. As for writing — God help us all, I’m not even up to snark, even ripe and ready for the picking.

At any rate, thanks for all the kind messages and advice. If there’s no improvement by tonight (which will be 72 hours of antibiotics), I’ll go get checked out again.

Me and the cat and my drippy ear are going back to bed.

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Perf

Judging from the outer ear canal crust this morning, I gather the infection and the pressure perforated my eardrum overnight. Frankly, I don’t know when I’ve felt so lousy. No post today, obviously, but a few autumnal garden photos.

Incidentally, does anyone have an opinion when I should get further attention? The treatment seems to be antibiotics (which I’m on) and time, but the ongoing pain, the hearing loss and general crapitudiness is a bit alarming.

Symphyotrichum novae-angliae (syn. Aster novae-angliae) 'Alma Potschke'. Who says fall gardens have to be dull?

More beneath the fold. Read the rest of this entry »

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Some Days You Just Gotta Post Links Vol. 3

In honour of a certain otitis media.

  • Some more really bad food. “Four adult men would have to share this entree in order to each stay within a day’s worth of saturated fat.”
  • Quackery. (Also reminds me of that nursing “diagnosis”, “Disturbed Energy Field.”)
  • Palliative care and chemo: “The care the palliative teams offer lets patients be more active, which means they stay healthier. They’re less depressed so they’re more likely to be out and about and keeping physically fit. Of course, they live longer.”
  • Also in prison news, this hasn’t been fixed: ” Court and prison documents obtained by the Star show how the young woman’s complaints of inhumane treatment were repeatedly ignored and how she wound up a “caged animal,” four years after first entering the correctional system for throwing crab apples at a postal worker.” See also here.

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An Earful

I’ve had this annoying little head cold for the past five or six days, but on Friday morning I began having sharp intermittent left ear pain which became more or less constant and severe by Sunday night. Ibuprofen and Tylenol #1 did nothing. I was waiting to see if would go away: I knew the vast majority of ear infections are viral (and won’t of course respond to antibiotics) and would resolve in any case on their own; also I didn’t want to be a bother, one of those people who runs to Emerg for trivial complaints.

But after a sleepless, pain-filled night enough was enough. I called my family doctor — no hope of an appointment today. So I had no choice: we trundled over to the local Emergency (Hi L.!), was mistriaged (of course), and waited three hours to see the physician.

My conversation with the doc went like this:

Me: I have a left ear infection, and the pain is so severe I can’t close my mouth.

Physician: It’s not likely you have an ear infection. I don’t like writing unnecessary prescriptions for antibiotics.

Me: The pain is ten out of ten.

Physician: (looks in ear) Why, it’s all red and very swollen!

Me: (to self) Well, duh. (to physician) I haven’t slept in two days, the pain is so bad.

Physician: (defensively) Ear infections are rare in adults.

Me: Can you give me something for pain?

Physician: (writes script) Oh, just keep taking ibuprofen. (Leaves.)

Me: Gnarl slah grrr  mutter roplph slnarl jackass.

All of which is a long way of saying that posts for the next few days may be erratic and/or non-existent while I de-distend my tympanic membrane and load up on Tylenol #1 (which, incidentally is OTC in Canada). Also, listening to your patients is a good thing.

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Favourite Poems XIX

I thought about inflicting presenting Gray’s Elegy Written in a Country Churchyard for my usual Poem-of-a-Saturday, but maybe I’ll save it for the bleaker days of November. Instead, something a little lighter, an ode for Horace Walpole‘s dead cat. Augustan English rhetoric, a sort of macabre charm and an anodyne moral or two: what more could you want? (The annotated poem can be found here. Illustrations by William Blake, somewhat after the poem was published. The full set to accompany the poem are here.)

Ode on the Death of a Favourite Cat, Drowned in a Tub of Gold Fishes

‘Twas on a lofty vase’s side,
Where China’s gayest art had dy’d
The azure flowers that blow;
Demurest of the tabby kind,
The pensive Selima reclin’d,
Gaz’d on the lake below.

II.
Her conscious tail her joy declar’d;
The fair round face, the snowy beard,
The velvet of her paws,
Her coat, that with the tortoise vies,
Her ears of jet, and emerald eyes,
She saw, and purr’d applause.

III.
Still had she gaz’d; but midst the tide
Two beauteous forms were seen to glide,
The Genii of the stream;
Their scaly armour’s Tyrian hue,
Through richest purple, to the view,
Betray’d a golden gleam.

IV.
The hapless Nymph with wonder saw:
A whisker first, and then a claw,
With many an ardent wish,
She stretch’d, in vain, to reach the prize.
What female heart can gold despise?
What cat’s averse to fish?

V.
Presumptuous Maid! with looks intent
Again she stretch’d, again she bent,
Nor knew the gulph between;
(Malignant Fate sat by, and smil’d.)
The slippery verge her feet beguil’d;
She tumbled headlong in.

VI.
Eight times emerging from the flood,
She mew’d to every watery God,
Some speedy aid to send.
No Dolphin came, no Nereid stir’d:
Nor cruel Tom, nor Susan heard.
A favourite has no friend.

VII.
From hence, ye beauties, undeceiv’d,
Know, one false step is ne’er retriev’d,
And be with caution bold.
Not all that tempts your wandering eyes
And heedless hearts, is lawful prize;
Nor all, that glisters, gold.

— Thomas Gray (1747)

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Happy Belated Autumnal Equinox

Okay, I know, two days late. Time to get out the camera for the inevitable two thousand pictures of Ontario’s spectacular fall foliage. I’ll try to resist the temptation of including old barns or waterfalls.

Day 3 of a head cold, feeling whacked out from the cough syrup, up half the night with an earache, Cat is spinny, freaked out by the sudden (and temporary) return of summer: I’m whiny and bitchy today. So no substantive post.

On the other hand, when I was up half the night, watching The Golden Girls on YouTube and taking T3s and decongestants for the earache, I finally got around to installing a new blog template. I rather tentatively like it — let me know what you think.

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At Veterans Affairs, Confidentiality is Meaningless

This story has been bouncing around the last day or so, but the more I think about it, the more disturbing I find it:

Confidential medical and financial information belonging to an outspoken critic of Veterans Affairs, including part of a psychiatrist’s report, found its way into the briefing notes of a cabinet minister.

Highly personal information about Sean Bruyea was contained in a 13-page briefing note prepared by bureaucrats in 2006 for then minister Greg Thompson, a copy of which was obtained by The Canadian Press.

The note, with two annexes of detailed information, laid out in detail Bruyea’s medical and psychological condition.

[snip]

The privacy documents show 614 people within Veterans Affairs accessed Bruyea’s computer file between 2001 and 2010, records that are kept in a password-protected computer database. Of those, 156 exchanged varying amounts of personal information, according to a trail of internal emails.

The material appears to have been shared with an additional 243 individuals, including both Liberal and Conservative political staffers, through briefing notes and emails during the 2006 transition between governments. [Toronto Star]

In health care, there is a term of art  — “circle of care” — which describes the health care professionals directly involved with a patient’s treatment, and by implication, those who have direct access to confidential information related to her or his care. For example, if you are hospitalized, your circle of care would include your primary nurse, your physician, and maybe some others — the physiotherapist, perhaps, or the social worker. Generally speaking, you can’t access the health records of any person outside the circle of care without explicit written consent of the patient. Papers need to be signed and so on.

I understand Veterans Affairs might need to request access to confidential medical records to assess benefits and treatment. What I’m having difficulty with is imagining circumstances where a cabinet minister, hundreds of bureaucrats, three senior civil servants, and staffers and various other flaks should have access to confidential medical information without permission. How is the Minister of Veterans Affairs part of the circle of care? Or, for that matter, a staffer in the PMO?

It’s disgraceful enough that the health care information of any Canadian, let alone a veteran, was used for political purposes. But the real scandal is the safeguarding within Veterans Affairs to protect confidential medical records of veterans. Apparently, there isn’t any.

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How a Police Officer Can Get a Nurse Fired

Full disclosure: I drive far too fast on the highway, and I’ve been pulled over once or twice by friendly City of Toronto or O.P.P. constables. I confess I have played the I’m-an-Emergency-nurse card, and usually get waved off with a warning, or at worst a nominal fine. It’s an unspoken courtesy: we’re all emergency workers, and while we might fight like family amongst each other, we stick together too, just like family.

But I would be lying to you if I said there wasn’t an element of quid pro quo, not in the actual care of any police officer, of course, but in the thousand other ways the police need our cooperation. You want to leave quickly with that drunken guy who needs sutures? The goodwill of many a nurse, I think, would be strained if they had just got a whacking fine for speeding. Ideally, this should not happen. Nurses should be fined appropriately for traffic violations, and police should not expect special consideration when they come to hospital for any reason. But the reality is our social and professional existence is greased with such ethical compromises.

This cop was definitely not playing by the rules (and thanks to EKyProgressiveblog and Twitter — for sending me the link):

When Colorado Springs cardiac nurse Miriam Leverington was stopped for speeding, she grumbled to the police officer.

“I hope you are not ever my patient,” she reportedly told him.

What happened next has become a topic of widespread debate in Colorado and on the blogosphere. The police officer, Duaine Peters, complained to the hospital where Ms. Leverington worked that her comment amounted to a threat, suggesting she might give him poor care should he ever become her patient.

The hospital fired the nurse, and now the nurse has countered with a lawsuit. She says she was merely exercising her right to free speech — and expressing her hope that she never see the policeman again.

Aside from the ambiguity of the nurse’s statement (it’s either a threat or, a strong declaration of dislike) is it ever appropriate for the police going to our places of work to complain about our mouthy behaviour? And is being punished by loss of employment maybe a little extreme for essentially telling a cop to flock off?

You get the sense two related things are going on here: nurses are being held to a far higher level of accountability* than the community at large, and this particular nurse violated social norms related to nursing: she wasn’t meek, deferential nor docile, and she had to be punished. I wonder if a paramedic or firefighter had made the same remark — both of whom operate in the charmed circle — the officer would have gone the same extreme to complain, and whether there would have been job losses as a consequence.

__________

*A topic, perhaps, for another post.

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Some Thoughts on “Independent” Nursing Practice

Over at Nurse Story, Terri Schmitt poses a question:

Being the rabblerousing heretical feminist that I am, I have always sought to think of nursing as part of the medical ‘team’ where all professionals provide input to build the best care of the patient. I am beginning to wonder if my pie-in-the sky view and push to have nurses see themselves as independent professionals with a unique body of knowledge is accurate?

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician. Although we have been trained to recognize these things, we carry an independent license, sit for an examination to obtain that license, and have had years of education. Perhaps nurses really cannot do any of these things without a supervising physician to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school and give him/her an independent license, scope of practice, and make them answerable to a board of nursing but then limit their usefulness? [emphasis mine]

It’s a good question and one I have pondered a lot, usually in the context of finding a work-around for physician obtuseness, or contemplating some idiocy from hospital administration.

First thought: sometimes pie-in-the-sky lets us think about possibilities, rather than limitations.

Next thought: the quick and easy answer is that nursing usefulness depends on where and how you practice. Institutional culture counts for much, especially when hospital administrators view nurses as a human resource problem to be “managed” and not professionals capable of independent judgement. (I suspect the institution mentioned by Terri has a particularly authoritarian workplace culture.) In most hospitals in Ontario, there are medical directives in place: formal documents which let nurses, using nursing judgement, to perform acts traditionally reserved to physicians. So in the Emergency Department, I can order x-rays and blood tests, give medications, defibrillate and so on, all without a physician order. Jurisdiction is important. In Ontario, for example, a nurse would be disciplined by the College of Nurses of Ontario, our professional regulatory body, for not holding that anti-hypertensive — and I don’t think I have ever asked for physician approval to flush a catheter, or to refer a patient to social work, diabetes education or home care. We can pronounce death, write DNR orders, and in certain circumstances, even start IVs without a physician order.

So well and good. The long and complicated answer: there is a dichotomy between the expectations of nursing as professionals and actual practice; it comes down to whether nurses are professionals in the same sense that physicians (among many others) are. I’m sceptical. In this case the word  “professional” conjures words like “independent judgement” and “autonomy”. It is somewhat difficult to imagine, except in some limited and particular circumstances, where nurses actually engage in independent judgement, decision-making and autonomy in the same way as physicians. We defer not only to physician orders, directives and judgement (which often see fit to determine and define practices clearly within the expertise of nurses), but also hospital policies and procedures and government regulation of our competencies. And as I have often argued, nurses do it to themselves. The culture of nursing hinders. We are resistant to change; we acquiesce all to readily to “superior judgement”; we don’t question why physicians and (increasingly) other health care professionals can write “orders”, and nurses can’t; we often refuse to learn new skill sets that would enhance our practice; we don’t push the envelope. All in all, it’s a picture where nurses are theoretically are professionals in the fullest sense, but practically we fall somewhat below the mark.

Last thought. I will speak the ultimate heresy: is it possible that the push for nurse practitioners as “advanced practitioners” was in the end damaging for the nursing profession as a whole? It consumed the energies of nurses’ associations for decades, lobbying governments and bureaucrats — and continues to do so —  so instead of arguing for advancing competencies and standards for all nurses, we focused on the independent practice and judgement of the few. The rest of us were left behind, even as other allied health professionals with comparable levels of education were granted authority to perform acts traditionally reserved for physicians. Was it worth it? Some days I am not sure. Terri mentions the difficulty and constraints in establishing nurse-led diabetic foot clinics — an area well within nursing scope of practice. Lobbying for nurses to do this sort of service independently — and there are plenty of other examples — and without direct physician supervision (which really represents a sort of unnecessary duplication) might have been more useful for both the profession and our patients.

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EMERGENCY!

The Object of My Hopeless Desire (centre right)

The television show, of course. For some God-unknown reason I fell to thinking of this program on the long drive home from one of those tedious, day-long meetings. It was a ’70s genre medical action show that tracked a pair of fire department proto-paramedics around Los Angeles. The dialogue, it seems to me now, was stilted, and the plots were formulaic and predictable. (It was television in the 70s, after all. However, plus ça change, plus c’est la même chose.)

Emergency! might have been the first television show that depicted the processes of emergency care, however dramatized; it’s been claimed the show influenced the general adoption of emergency medical services in North America and around the world — and it certainly had a lasting cultural influence. There were a couple of good-looking paramedics  (ur-paramedics?), a lot of high tech gadgetry which must have seemed like magic, including a radio that transmitted ECGs, big noisy pieces of rolling stock, an alphabet soup of medicalese, a base hospital (“Rampart General”), some avuncular doctors, and also a white-clad-and-capped nurse, Dixie McCall. Her principal job, it seems, was to answer the patch radio and crack wise, while the “men” did the important work. Like I said, nothing ever changes.

At any rate, I can’t say Emergency! influenced me in any way whatsoever in becoming an emergency nurse — the road to my present exalted position is long and convoluted. (If I had figured Nurse McCall in my calculations, I probably would have run the other way. Dixie McCall, though, might be the prototype for the crusty ED nurse.) I was, however, desperately in love with the paramedic played by Randolph Mantooth. I was 12 or 13, a hopelessly geeky misfit, friendless and desperately lonely. I got instructions on where to write television actors from some gossip magazine, and it was to him I composed my first (and only) fan letter.

Dear Mr. Randolph Mantooth (I wrote)

I am 12 years old and really like your television program. I watch it every week. I live in Toronto, Ontario, Canada. It is very cold here in the winter, and I know in Los Angeles it is always sunny and warm. I am very lonely. I don’t have many friends and I hope you will be my friend and write me back.

Your friend

My mother found this letter on my desk. She was not sympathetic — she viewed herself, I think, as the perpetual inquisitor and judge of my character and development — and the letter made her angry. “The reason why you’re so lonely,” she said, in a kind of self-evident tautology, “is that you don’t know how to make friends.” (She didn’t quite call me ugly or dull or slow, but nevertheless, she was very good at assigning blame. Almost needless to say, I left home at the first possible instant.) She threw away the letter.

Funny how thinking about an old television show can dredge up formative, unpleasant memories. Perhaps better left forgotten? Or perhaps makes for creativity?

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